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Alabama Association of School Nurses Concussion (and a quick mention of Neck Injuries) Update and Review June 1, 2011. Robert S. Gilbert, DO. AKA “Dr. Bob”
AKA “Dr. Bob”
Premier Urgent and Family Care firstname.lastname@example.org
4643 Camp Coleman Road, Suite 117 Office: (205) 655-4924
Trussville, AL 35173 Fax: (205) 655-5059
Position Family Practice Physician
04/2010 to Present Premier Urgent and Family Care, Managing Partner
10/1997 to 04/2010 Emergency Department with over 25,000 clinical hours in level two and three facilities.
12/1997 to 07/2001 University of Alabama at Birmingham, Assistant Professor of Family Medicine
10/1997 to Present Board Certified in Family Medicine
7/1994 to 6/1997 The University of Alabama at Birmingham, Family Medicine Resident
9/1990 to 5/1994 New York College of Osteopathic Medicine
Basic Life Support, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Advanced Trauma Life Support, Advanced Airway Management, Alabama Ems Online Director, Moderate Complexity Laboratory Director
The American Academy of Neurology
Concussion is a trauma-induced alteration in mental status that may or may not be associated with loss of consciousness.
The Third International Conference on Concussion in Sport
Concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
Who showed up?
Centre for Health, Exercise and Sports Medicine, University of Melbourne, Australia
Sport Medicine Centre, Faculty of Kinesiology and Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada
Sport Concussion Clinic, Toronto Rehabilitation Institute, Toronto, Ontario, Canada
FIFA Medical Assessment and Research Center and Schulthess Clinic, Zurich, Switzerland
Ottawa Sport Medicine Centre, Ottawa, Canada
Huguenot House, Dublin, Ireland
Emerson Hospital, Concord, Massachusets, USA
What was the plan?
Develop conceptual understanding of concussion in sport using a formal consensus-based approach.
Develop guidelines for use by physicians, therapists, athletic trainers, health professionals, coaches and other individuals involved in the care of injured athletes, whether at the recreational, elite or professional level.
Just for kicks…
The Zurich consensus makes a distinction between Concussion and Mild Traumatic Brain Injury (mTBI) and does not recommend they be used interchangeably.
(Problem is… they didn’t define mTBI!)
What did they come up with?
Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with impulsive force transmitted to the head.
Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously.
Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury.
Concussion may result in a graded set of clinical syndromes that may or may not involve LOC.
Resolution of the clinical and cognitive symptoms typically follows a sequential course.
Post-concussive symptoms may be prolonged in a small percentage of cases.
Concussion shows no abnormality on standard structural neuroimaging studies.
What is it called?
The Old System – NO LONGER USED!
Grade 1: Transient confusion, no loss of consciousness (LOC)
and all symptoms resolve within 15 min.
Grade 2: Transient confusion, no LOC, but symptoms or mental
status abnormalities persist longer than 15 min.
Grade 3: Any LOC, either brief (seconds) or prolonged (minutes).
Concussion grading based on the presence or absence and duration of loss of consciousness, confusion, and posttraumatic amnesia have not been shown to be clinically useful in the management of concussion.
Grading a concussion with the intent of then determining severity and to return to play has been abandoned.
The severity of concussion in an individual athlete can only be ascertained retrospectively after full clinical recovery has occurred.
How often does it happen?
Annually there are approximately 2-4 million concussions in all age groups.
Approximately 300,000 head injuries occur yearly in high-school sports.
Concussions comprise 90% of head injuries.
Concussions comprise 8.9% of all high-school athletic injuries.
Concussion occurs at a rate of 6 to 25% of high school players per season.
Males account for 70%.
30% of high-school and collegiate athletes return to play the same day,
and 70% after 4 days.
80 – 90% of concussions resolve within 7 to 10 days.
Athletes may not report symptoms or head injury for fear of being excluded from participation.
It is generally accepted the reported incidence of concussion is a gross underestimate.
In a study of high-school football players with concussion:
47.3% reported their injury.
52.7% did not report their injury because:
66% did think their injuries were serious enough to report.
36% did not realize their symptoms were consistent with concussion.
41% did not want to be held out of play.
The highest number of concussions occur football, followed by ice hockey, soccer, wrestling, basketball, field hockey, baseball and softball.
Athletes who have ever had a concussion are at increased risk for another concussion.
Injuries are most often reported to Athletic Trainers.
Why Did It Happen?
Concussion occurs as a result of sudden acceleration, deceleration, or rotational forces imparted to the brain with or without direct impact.
Mechanism of injury may be subtle and not obvious.
Magnitude of impact does not correlate with clinical injury.
Concussion can also occur in noncontact sports.
Concussion is related to dysfunction of brain metabolism rather than structural injury or damage.
Concussion on a cellular level is characterized by disruption, increased permeability, and depolarization of neuronal cell membranes resulting in neuronal suppression.
The increased cellular metabolic activity increases the need for energy and glucose.
A complex cascade causes decreased blood flow to the brain creating a mismatch between metabolic demands and supply.
This results in neuronal dysfunction that can last from 1 to 10 days or more following the concussion, during which time the brain is more vulnerable to further injury.
A second concussion seen in an athlete who still has persistent symptoms or has not clinically fully recovered from the previous concussion.
It is unclear whether Second Impact Syndrome represents a new brain injury or is a complication of the initial injury.
Rapidly progressive brain edema.
Brain stem herniation.
High mortality within minutes.
Mental Status Changes
Amnesia– Retrograde / Anterograde
Feeing Dinged, Stunned, or Foggy
Impaired Level of Consciousness
Inappropriate Play Behaviors
Loss of Consciousness
Poor Concentration and Attention
Seeing Stars or Flashing Lights
Slow to Answer Questions or Follow Directions
Loss of consciousness only occurs in 10% of concussions.
Physical or Somatic
Ataxia or Loss of Balance
Blurry vision / Double vision
Decreased performance or Playing Ability
Dizziness / Vertigo / Lightheadedness
Fatigue / Weakness
Insomnia / Hypersomnia
Nausea / Vomiting
Ringing in the Ears
Slurred or Incoherent Speech
Vacant stare / Glassy Eyed
A Word on Seizures…
A variety of immediate motor phenomena (e.g. tonic posturing) or convulsive movements may accompany a concussion.
Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.
… Yeah, Whatever….
Behavioral or Psychosomatic
Anxiety / Nervousness
Depression (May be Long Term)
Low Frustration Tolerance
Headache That Gets Worse and/or Persistent
Loss of Consciousness > 1 Minute
Repeated Vomiting or Nausea
Weakness / Numbness / Decreased Coordination
There are no tests to “prove” an individual has sustained a concussion.
Concussion implies a more severe injury, such as a brain contusion or bleed,
is not present.
Concussion is a diagnosis of exclusion.
Common Concussion checklists include:
Concussion Resolution Index
Concussion Symptom Inventory
Head Injury Scale
McGill ACE Post-concussion Symptoms Scale
Pittsburgh Steelers Post-concussion Scale
Post Concussion Symptom Scale
Post-concussion Scale Revised
Standardized Assessment of Concussion (SAC)
Sports Concussion Assessment Tool 2 (SCAT2)
Concussed athletes scored 29% better on the SAC at the time of their injury compared with their baseline evaluation.
Noun or Verb; perhaps from Greek skat-, skōr excrement
An animal fecal dropping
Jazz singing with nonsense syllables
To go away quickly
To move fast
What to look for?
Findings on neurologic examination should be normal with concussion,
other than the mental status or cognitive functions.
Abnormal or focal findings on neurologic examination prompt consideration of intracranial pathology and emergent evaluation and management.
Children are particularly prone to drowsiness, vomiting, and irritability, which are sometimes delayed for several hours after apparently minor injuries.
Eyes: Extraocular Movements, Ocular Fundi, Pupil Reaction,
Visual Acuity, Visual Fields
Postural stability has been shown to be a sensitive indicator of sensory-motor dysfunction in concussion.
A variety of balance testing options are available including:
The Sensory Organization Test on the NeuroCom Smart Balance Master System Balance Error Scoring System (BESS)
The Modified BESS
“when in doubt, sit them out!”
Have an emergency action plan and concussion protocol in place.
A B C D E
AAOX3 is not reliable.
Glasgow Coma Scale
Sport Concussion Assessment Tool 2 (Scat2)
Sideline assessment tools are not designed to take the place of more comprehensive evaluation or testing.
Some symptoms may appear right away, while others may not be noticed for days or months.
Glasgow Coma Scale
I. Motor Response6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No response
II. Verbal Response 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No sounds
III. Eye Opening 4 - Spontaneous eye opening 3 - Eyes open to speech 2 - Eyes open to pain 1 - No eye opening
The final score is determined by adding the values of I+II+III.
Approximately 10% of patients with a GCS of 15 will have an acute lesion on non contrast head CT.
Many symptoms of concussion are not specific to concussion.
This creates a difficult dilemma in making the diagnosis.
Differential Diagnosis in athletes include:
Acute Exertional Migraine
When to send?
Drowsy or Cannot be Awakened
Headache That Gets Worse and/or Persistent
Increasing Confusion, Restless or Agitation
Loss of Consciousness > 1 Minute
Repeated Vomiting or Nausea
Weakness / Numbness / Decreased Coordination
Tests typically performed at least 24 to 48 hours after injury, when the athlete is symptom free, and when compared with preseason baseline tests.
Neurophysiologic testing should be interpreted by a Neuropsychologist.
The advantage is the ability to test athletes without neuropsychologists having to administer the tests.
The validity of computer-based neurophysiologic testing in sport-related concussions remains unsettled.
The performance of computerized neurophysiologic tests seems to be variable, but better than pencil-and-paper tests.
The same neurophysiologic test suite needs to be used for baseline and post injury evaluation.
(Automated Neuropsychological Assessment Metrics)
Developed by the United States Department of Defense.
Assess how normal physical and cognitive performance might be affected by chemical warfare agents.
ANAM has been used for evaluation of other types of injuries, including concussion in athletes.
ANAM scores do not measure or indicate return to baseline after a concussion.
Measures psychomotor function, processing speed, visual attention, vigilance, visual learning, verbal learning, and memory.
The suite is sensitive to cognitive changes seen in sport-related concussions compared with baseline performance, which is necessary for the evaluation of an athlete after concussion.
(Concussion Resolution Index)
Web-based test that includes measures of cognitive functions related to postconcussion syndrome.
Includes memory, reaction time, and speed of decision making and of information processing.
CRI was developed specifically to allow for comparison of an athlete’s baseline and postconcussion performance.
(Immediate Postconcussion Assessment and Cognitive Testing or Immediate Measurement of Performance and Cognitive Testing)
Designed specifically to evaluate NP function in athletes at baseline and after concussive injury.
One of the most widely used test suites for evaluation of concussion in athletes, including professional players.
(Standardized Assessment of Concussion)
A brief examination intended for use at the sideline.
Based on the American Academy of Neurology’s 1997 Practice Parameter for management of sports-related concussion.
An electronic version operating on handheld personal digital assistants is available.
Following a concussion, complete physical and cognitive rest is recommended.
Educational accommodations for athletes recovering from concussion:
Reduce the number of work assignments
Allow more time to complete class work
Allow more time for tests
Outline and break complex tasks into simple steps
Provide written instructions
Provide distraction-free areas for work
Provide a note taker
Incorporate less stressful course work
Cognitive rest also implies limiting such activities as playing video games, texting, and watching television during the recovery period.
There are NO accepted guidelines for return to play.
DO NOT follow the conventional return-to-play guidelines.
A more conservative RTP approach is now recommended because of the different physiological response, longer recovery time, and specific risks
(e.g. diffuse cerebral swelling) during childhood and adolescence.
An individualized, stepwise plan for return to play is now the preferred practice.
Each athlete follows a variable time course to recovery from acute cerebral concussion.
Any abnormality on CT or MRI scans should result in termination of the season, and return to play at any future time should be discouraged.
The National Collegiate Athletic Association (NCAA) and
The National Federation of State High School Associations (NHFS)
Removal from play once any signs or symptoms of concussion are present.
Cannot return to play the same day.
Immediate evaluation by a health care provider trained in concussion management.
Evaluation by a physician or their designee before return to play.
Most practitioners consider at least 7 to 10 days of rest before beginning the Zurich recommendations.
This will protect vulnerable cells and axons by minimizing cerebral glucose demands and avoiding additional strains on cerebral blood flow.
Before the athlete is allowed to start the return to play guidelines,
they must be:
Asymptomatic at rest.
Asymptomatic on exertion.
Examination must be normal.
The Zurich Conference Consensus Statement stepwise approach.
1. No activity; complete physical and cognitive rest
(e.g. scholastic work, video games, text messaging).
2. Light aerobic exercise
Walking, Swimming, Stationary Cycling.
Keep intensity <70% maximal predicted heart rate.
NO resistance training.
3. Sport-specific exercise.
NO head impact activities.
4. Noncontact training drills with progression to more complex training drills.
Start resistance training.
5. Full-contact practice following medical clearance.
6. Return to unrestricted sport participation.
The athlete should continue to proceed to the next level if asymptomatic.
If symptoms recur, go back to the previous asymptomatic step and try to progress after 24 hours of rest.
The adverse effects of repeated concussions on the brain are cumulative and greater as the interval between successive concussions gets shorter.
Multiple concussions have been associated with cumulative effects on cerebral function and cognition, including early onset of memory disturbances and even dementia.
There is no agreement as to how many concussions in a given period of time should disqualify the athlete from further participation in high-risk sports.
Some have suggested as few as three.
Emergency Concussion Action Plan
These programs should include:
Concussion education programs for athletes, parents, and coaches focusing on recognition, the recovery process, and return-to-play guidelines.
Guidelines for faculty, administrators, parents, and students to ensure cognitive rest.
Concussion-prevention strategies including proper fit and maintenance of protective equipment, teaching correct sport technique, and proper maintenance of fields and facilities.
Baseline and post-concussion neurocognitive testing for student athletes.
Strict accident reporting protocol for coaching staff.
The mean incidence of catastrophic neurological injury over the past 30 years has been approximately 0.5 per 100,000 participants at high school level and 1.5 per 100,000 at the collegiate level.
0.2 per 100,000 participants at the high school level and 2 per 100,000 participants at the college level are diagnosed with cervical cord neuropraxia.
It has been reported to occur in 50-65% of players over a 4-year collegiate career.
The mechanism of catastrophic cervical injury is most often a forced hyperflexion injury.
The relatively common 'stinger' is a neuropraxia of a cervical nerve root(s) or brachial plexus and represents a reversible peripheral nerve injury.
Characterized by temporary pain, paraesthesias and/or motor weakness in one or more extremity.
These 'stinger' or 'burner' injuries are characterized by unilateral burning pain radiating from the neck, down the arm to the hand.
There is a rapid and complete resolution of symptoms and a normal physical examination within 10 minutes to 48 hours after the initial injury.
ABCDE approach should be utilized.
Airway is first assessed while maintaining cervical spine stability
Breathing and ventilation
Disability (neurological status)
Exposed for the secondary survey
The athlete's helmet and shoulder pads should remain in place with immobilization of the cervical spine.
The helmet and shoulder pads serve to provide support and alignment to the injured cervical spine.
The hard collar does immobilizes the neck to a substantially greater degree than a soft collar, but it is very poor at controlling rotational movement.
The range of flexion decreases from 35° in unrestrained volunteers to 24° in a
No set of guidelines for return to play is agreed upon.
Relative contraindications to return to play include:
Symptoms lasting >24 hours
Absolute contraindication to return to play
Persistent neck pain or loss of motion
Edema in the spinal cord
the athlete sustaining a stinger may return to play when the paraesthesias resolve and full strength and painless full range of neck motion are appreciated.
The patient must be able to demonstrate a full, painless cervical range of motion and have no evidence of neurological deficit prior to returning to play.